The second Covid wave is ebbing in India. From a peak of 4,14,433 cases and 4,487 deaths on May 6, 2021, the country reported only 40,000 cases and about 500 fatalities on July 18. Further, India has substantially “unlocked” for work and education.
Data suggest that there has been a tragic loss of lives, with about 4,00,000 people succumbing to the virus and over three crore people suffering in various ways due to the disease. The economic, social and medical cost of this pandemic is incalculable. But the silver lining is that the vaccine is now available and a substantial population of the country might have already been infected without reporting any symptoms and thus they may be immune to the virus.
Recent sero-surveillance study from Ahmedabad reports that 81 per cent of sampled individuals have antibodies against Covid. While Ahmedabad cannot be an outlier – other big cities are likely to have similar levels of immunity. Unless we are very unlucky and a new immunity evasive strain develops the chances of a third wave seem to be low. But, we, as a nation should not be complacent. We must follow Covid appropriate behavior till the pandemic is past us.
Further, in the future to be able to deal with such a catastrophe, we must build an army of public health personnel. This pandemic has shown many weaknesses in our public health system. Public health work includes surveillance, control of epidemics, tracing, testing, isolating cases, keeping health statistics and mortality statistics, undertaking prevention of disease by vaccination, social distancing, lockdowns etc. This is really the job of the government and its agencies. Private sector will have no role to play here as there is no private market for these kinds of jobs.
While, Covid-19 killed 400,000 people, TB kills about the same number of persons in India every year. But we as a nation are not paying much attention. Simple diarrhea and childhood pneumonia kills millions of children in the country. Hence to prevent all such infectious diseases we need a solid public health human resource infrastructure on the lines of IAS or IFS type centralized cadres. Unless we develop such a public health workforce and administrative cadre we will be lagging in future pandemic response. The way people had to struggle during the first and second Covid wave can only be prevented in case of a future pandemic with very strong public health measures. Given India’s size we need between 10-20 thousand well trained public health officers to manage our public health and primary care system. USA with its 30 crore population has 6,000 public health service staff which are part of the US Navy. It is multidisciplinary and fully government funded. Such cadre in India should be composed of public health graduates with MPH or MD/PhD degrees in public health, community medicine, epidemiology, demography, health statistics, health informatics, microbiology, etc. Each district will need about 10-15 such officers and staff with different skills. India has 740 districts and about 8000 towns, cities and urban areas. They will each need a hierarchy of public health officers on lines of collector, deputy collectors, and other revenue officers. This is eminently doable in the next 2-3 years. The new health minister is a dynamic young politician with his feet on the ground and will definitely take this up as a new challenge to plan and implement such a cadre. We present a structure and function of such a public health system here.
The chief district health officers should be MD in community medicine or MBBS with P G Diploma in Public health management or MPH. This PG diploma in Public Health management was created for such leadership position at taluka and district level under National Health Mission. At the taluka level the public health programs should be looked after by a set of public health program officers – may be 3-4 in each taluka. The work of surveillance of Tb, Malaria, Degue, hepatitis, diarroes etc, birth and death registration and analysis, control of infectious diseases outbreaks, health education and behavior change, managing public health laboratory for testing of infections etc will be done by such public health officers and staff. At the PHC level which is for every 30,000 populations there should be one medical officers for clinical services which is already there, but we should add a public health officers for preventive and public health services such as MCH, immunization, disease control, control of malnutrition, ensuring mosquito control and pure water and sanitation etc. Such officers should have MPH degree or PG diploma in Public Health management. Similar pattern can be replicated for urban areas at ward level. These officers will supervise the public health nurses, health supervisors, lab technicians, ANM and Asha at the community levels for implantation of national public health programs.
In the covid pandemic we could not easily even count the number of cases, hospitalizations, and deaths. There were lot of controversies on these numbers. WHO suggested surveillance of Influenza like Illness (ILI) or Severe Acute Respiratory Illness (SARI) did not happen systematically, the contact tracing, testing and isolation also was not happening to the optimal level. All this can be improved if we have proper public health workforce. All medical doctors are not public health experts – they largely learn the medical diagnosis and curative care but are very weak in public health methods. Health education and behavior change in the community needs social scientists with public health training and not doctors or nurses. Thus a well-trained multidisciplinary public health work force is very essential to create for India to face next pandemic and control regular epidemics. The price as a society we have paid and are paying due to infectious diseases is enormous. As compared to this the additional cost of such public health workforce is small. India we must do this now – create a multi-disciplinary public health work force of international standards.
(Dr Dileep Mavalankar is the Director at IIPHG and Dr Deepak Saxena, is an affiliate of PHFI. Views expressed are personal and do not reflect those of Outlook Magazine.)